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Question 1 of 14
What is your best email?
Question 2 of 14
What is your cell phone number?
Question 3 of 14
Please enter your Full Name
Question 4 of 14
How did you hear about us?
Amazon (#1 Best Seller Winning Wellness Method)
Question 5 of 14
If someone referred you to Winning Wellness & Physical Therapy, please state the name of the person or clinic. Please put "N/A" if no one referred you.
Question 6 of 14
What’s the primary reason for wanting to speak to a specialized Registered Dietitian?
Question 7 of 14
What is your main problem or concern?
Question 8 of 14
How long have you struggled with this?
Haven’t- This is prevention (not cure)
Too long (years)
Question 9 of 14
What’s your greatest worry about your current situation?
Question 10 of 14
What are your current goals?
Question 11 of 14
How committed are you to achieving those goals?
A little committed
Question 12 of 14
Where would you want your health and weight to be in the next 6 to 12 months?
Question 13 of 14
What made you apply today of all days? Is there anything else that we should know?
Question 14 of 14
I understand that in order for me to get results I must take action and COMMIT to the process. I understand that this is a SUCCESSFUL process, but a process nonetheless.
Yes, I understand.
No, I am not willing to commit.